Community Health Assessment & Community Health Improvement Plan, 2022–2024
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THE PREVENTION AGENDA is the blueprint for state and local action to improve the health of New Yorkers in five priority areas and to reduce health disparities for racial, ethnic, disability, low socioeconomic groups, and other populations who experience them. (NYSDOH Prevention Agenda website)
The Community Health Assessment (CHA) describes the health of the community by presenting information on the health status, community health needs, resources & assets, and health services infrastructure. It includes a socio-demographic profile of the county and identifies target populations that may be at increased risk of poor health outcomes. The CHA also assesses the larger community environment and how it relates to the health of individuals. New York State public health law requires all local health departments to produce a written community health assessment.
The Community Health Improvement Plan (CHIP) is a local-level, community-informed outline for addressing the most salient Prevention Agenda priorities in Tompkins County.
Prevention Agenda Priorities and Focus Areas
Tompkins County, 2022–2024
The NYS Prevention Agenda provides guidance for addressing the Focus Areas. Goals and objectives that span the needs and opportunities of each Focus Area are defined, and intervention strategies and process measures are identified. The goals for this Community Health Improvement Plan (CHIP) are as follows:
|NYS Prevention Agenda Priority||Focus Area||Goal||At-Risk Populations Addressed|
|Prevent Chronic Disease||CD-1: Healthy Eating and Food Security||CD-1.3: Increase food security||Poverty/ low income; Town of residence/ geography|
|CD-4: Preventive Care & Management||CD-4.1: Increase cancer screening rates for breast, cervical, and colorectal cancer screening
CD-4.2 Increase early detection of cardiovascular disease, diabetes, prediabetes and obesity
|Poverty; Residence/ geography; Race|
|Promote Healthy Women, Infants, & Children||HWIC-2: Perinatal and Infant Health
HWIC-4: Cross Cutting Healthy Women, Infants, & Children
|HWIC-2.1: 2.1: Reduce infant mortality & morbidity
HWIC-4.1: Reduce racial, ethnic, economic, and geographic disparities in maternal and child health outcomes, and promote health equity for maternal and child health populations
|Poverty (Medicaid recipient); Race; Residence /geography|
|Promote Well-Being & Prevent Mental and Substance Use Disorders||WB-1: Promote Well-Being||WB-1.1: Strengthen opportunities to build well-being and resilience across the lifespan
WB-1.2: Facilitate supportive environments that promote respect and dignity for people of all ages
|Poverty; Social isolation; Persistent mental illness|
|WB-2: Prevent Mental and Substance Use Disorders||WB-2.2: Prevent opioid overdose deaths
WB-2.3: Prevent and address adverse childhood experiences
WB-2.5: Prevent suicides
|Poverty; Residence/ geography; Race Persistent mental illness|
Community Health Assessment & Community Health Improvement Plan
The Tompkins County Community Health Assessment and Improvement Plan is a collaborative process with a focus on promoting health equity. Health equity occurs when every person has fair and just opportunities for optimal health and well-being. The integration of mental, physical, and environmental health allows us to envision a future where every person in Tompkins County can achieve wellness. This vision captures the recent combining of the local health department (LHD) and mental health services into one organization, Tompkins County Whole Health (TCWH). TCWH looks forward to working with partners and the community in this new capacity.
The Prevention Agenda (PA), New York State’s blueprint for “the healthiest state,” includes five Priorities: Prevent Chronic Disease, Promote a Healthy and Safe Environment, Promote Healthy Women, Infants, and Children, Promote Well-Being and Prevent Mental and Substance Use Disorders, and Prevent Communicable Disease. Each priority is divided into two or more Focus Areas.
Tompkins County selected two Focus Areas in the Prevent Chronic Disease priority, two in Promote Heathy Women, Infants, and Children, and two in Promote Well-Being and Prevent Mental and Substance Use Disorders. Objectives address food security and healthy eating, gaps in cancer screening, equity of care for women and infants, and opportunities to build and strengthen well-being.
Disparities are primarily across wealth and race. Inequity is also evident in housing and access to healthcare, with the latter often due to lack of transportation options. Secondary data shows an income gap between races.
Secondary data for the CHA were primarily sourced from the U.S. Census and the NYSDOH. The DOH pulls data from a variety of sources and compiles key indicators in the PA dashboard and the NYS Community Health Indicator Reports (CHIRS). These same sources have been the references for all editions of the Tompkins CHA.
Primary data was collected directly from the community through a community wide survey in which respondents were asked to rate their own health, identify choices and challenges, and weigh in on what makes a healthy community. Over 1,500 eligible responses to the survey were completed. The results clearly demonstrate the influence that social determinants of health have on an individual’s perception of their health.
A Steering Committee was convened to review and coalesce all data, and to propose the PA priorities and Focus Areas most relevant to the Tompkins County community. The committee included representatives from County Whole Health, County Youth Services, Office for the Aging, Cayuga Health, Health Planning Council, Cornell University MPH Program, and Cornell Cooperative Extension of Tompkins County (CCE-TC).
The array of programs active in Tompkins County to address social determinants of health drive strategies that are evidence-based, promising/pilot programs, and/or programs planning an expansion to serve new constituencies. These activities are aligned with CHIP goals and objectives identified by the steering committee. Promoting chronic disease activities focus on increasing the availability of fruit and vegetable incentive programs, screening for food insecurity, removing structural barriers to cancer screening, and promoting strategies to improve detection of hypertension and prediabetes.
Well-being relates to an individual’s physical, mental, and social sense of health and satisfaction, along with the influence that social determinants have on experiences and quality of life. The CHIP outlines strategies to strengthen well-being and promote health equity, including in the home to support parents and young children in families, and support those living with a chronic disease or disability to learn and practice techniques to better manage their disease in a safe, social setting.
It takes a supportive community to build well-being, and the CHIP specifies that Mental Health First Aid (MHFA) courses be taught to an ever-widening audience throughout the county, including at workplaces in all sectors. The CHIP identifies activities to prevent and treat mental and substance use disorders, including increasing access to medication-assisted treatment, access to overdose reversal training and kits, and integrating trauma-informed approaches in training and policy.
Evaluating the impact of the goals, objectives, and interventions presented in this CHIP will take place through 2024. A steering committee will monitor short term process measures that track activities. Community partners will have access to a reporting matrix that will be updated quarterly and on an annual basis submitted to NYS.
Download all sections of the 2022-2024 CHA & CHIP, and CHIP Workplan Matrix
Table of Contents and Executive Summary (PDF, 7pp)
- Population, Focus areas, Equity, Challenges (PDF, 63pp)
- Summary of Assets and Resources, Process and methods (PDF, 21pp)
- Community Health Improvement Plan (PDF, 31pp)
- Appendices & Sources (coming soon)
Download the complete CHA & CHIP narrative (PDF, 105pp, 2.5MB)
CHIP Workplan Matrix
The workplan matrix is entered into an Excel spreadsheet that has been pre-formatted by the NYSDOH. The matrix columns include PA goals and objectives, evidence-based interventions selected from the Prevention Agenda, process measures, projected intervention status for 2023, and partners and collaborators.
A PDF file of the Workplan Matrix is here.